HomeMy WebLinkAboutBLDG-24-186 MASSACHUSETTS UNIFORM APPLICATION FOR A PE MIT TO PERFORM GAS FITTING WORK
t r=r CITY //1�6 19- �y � Y MA DATE ". PERMIT\ #ai y-�a '/_
JOBSITE ADDRESS `)tl�tJ/vt/ , T OWNER'S NAME U IM/-T s
G01MJER ADDRESS 5A-74 t r% TEL FAX_
PR
CLEARLY OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Q�
CLEARLY NEW: ENOVATION: REPLACEMENT:O------
PLANS SUBMITTED:YES❑ NO 0
APPLIANCES Z FLOORS-. BEM 1 2 3 4 5 6 7 6 9 10 11 12
BOILER 13 i4
BOOSTER __
CONVERSION BURNER ^ �_
COOK STOVE i---
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE _ -+rt
GENERATOR /7 T' r �`f
GRILLE
INFRARED HEATER ] ��
LABORATORY COCKS 1 ZU:4
MAKEUP AIR UNIT
OVEN 'i bo_O,'',r,t,E ARrsEN
�----
AIM I
POOL HEATER "_---„
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST - _ _
UNIT HEATER �• _
UNVENTED ROOM HEATERI
WATER HEATER
OTHER
r
INSURANCE COVERAGE l
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
J SIGNATURE OF OWNER OR AGENT
,-,1: I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4,1
PLUMBER-r, ML9 LICENSE#`� 1� SIGNATURE
MP MGF /JPP� ' JGF LPGI❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY N F.� /; .(,' y- f ADDRESS )7
CITY �// /L/Yril✓ t//1 marr ``r/7 3 TEL
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES